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-i think that to publish or not to publish is the main problem, even being an important one -in fact, perhaps the main problem is the "manipulation" of the evidence -the outcomes are products of low quality, as this ironic "overview of the review" shows Revisiones de revisiones de medios virtuales en el manejo del peso. Baja calidad. *An overview of review of mobile and Web 2.0 interventions for weight management. Poor quality.* http://eurpub.oxfordjournals.org/content/26/4/602 -un saludo juan gérvas 2016-10-24 15:16 GMT+02:00 Benson, Teresa <[log in to unmask]>: > Glad this is being brought up. A few years ago when I was researching the > literature on applied behavior analysis for autism, I found something like > 3 RCTs and 8 systematic reviews. (Obviously, performing RCTs with autistic > children is a lot more difficult and time-consuming than just doing a > systematic review.) > > > > *Teresa Benson* > > Clinical SME, Evidence-Based Medicine > > McKesson Health Solutions > [log in to unmask] <[log in to unmask]> > > *From:* Evidence based health (EBH) [mailto:EVIDENCE-BASED-HEALTH@ > JISCMAIL.AC.UK] *On Behalf Of *Juan Gérvas > *Sent:* Sunday, October 23, 2016 4:31 AM > *To:* [log in to unmask] > *Subject:* Re: Check this paper...EBM a movement in crisis? > > > > -too little number of new RCT and to many systematic reviews and > meta-analysis > > *John Ioannidis. Debate about the abuse of systematic reviews and > meta-analyses.* > John Ioannidis. Debate sobre el abuso de revisiones sistemáticas y > meta-análisis. ¡Crecen + q los e*nsayos clínicos!* > *https://www.ncbi.nlm.nih.gov/myncbi/john.ioannidis.1/comments/ > <http://cp.mcafee.com/d/avndy0Ad39J5wsejhhovd79ISyyCyYOC--yrhhjhupjsphdCPpJmNnWkH3BPtQjhOqehld3O0HuVEVhsKwMaWXoQsyH5ZYlQsgYlpQQsFKFLKuZpQSrdCPpesRG9pxjEm8iW1WLgAjUzkPyFq5y4I4qAUtaKMx92lehNtnUjFxISOeuudCXCQPrNKVJUSyrh>* > > -un saludo juan gérvas @JuanGrvas > > > > 2016-08-28 23:34 GMT+02:00 Huw Llewelyn [hul2] <[log in to unmask]>: > > I was one of the contributors to this paper. I fully support the idea of > EBM. I was taught by Cochrane as a student. The concept of EBM has always > been embedded in me from the beginning. > > > > However, there are huge gaps in EBM as currently conceived. RCTs are > performed without specifying the evidence for adopting the diagnostic tests > etc used for choosing the patients to be entered into the RCT Andy the > cut-off points for those tests. There seems to be a naive idea that the > choice of 'gold standard tests' is self evident. It is a failure to address > this issue that causes over-diagnosis, over-treatment etc. > > > > Another problem is that the differential diagnostic process and the choice > of tests and other findings for use in it is not evidence-based. The > differential diagnostic process is being ignored by EBM research. I explain > in the Oxford Handbook of Clinical Diagnosis why Bayes simple rule with > sensitivity and specificity / false positive rates is inappropriate for > this process. Another theorem is required based on Bayes expanded rule and > a dependence assumption. > > > > Until these and other issues are addressed, then EBM research as currently > done will remain inadequate for my work as an experienced physician (and > mathematician). > > > > Dr Huw Llewelyn MD FRCP > > Aberystwyth University > > > Sent from my iPhone > > > On 28 Aug 2016, at 14:32, Anoop B <[log in to unmask] > <[log in to unmask]>> wrote: > > This article has been discussed here before. Most of the criticisms of > EBM- although right- are just simply criticisms of scientific research and > not a direct criticism of EBM. > > > > For example, the problem of doing research for profit, too much evidence, > marginal gains and poor fit for multi morbidity. All these points towards > the way research is carried out . EBM cannot control why and how someone > does research and their motives. I feel like these criticisms should be > specifically aimed at the conduct and reporting of research to gain any > traction, like what Loannidis is doing. They are barking at the wrong tree > , I feel. > > > > Also, most of their recommendations for improvement is what EBM has always > recommended. For example, making patient care the top priority, share > decisions, expert judgement and so forth. Remember the saying, 'evidence is > not enough' is one of the critical motto's of EBM. Clinical rules without > considering patient values and preferences is not and never was, EBM. > > > > Anoop > > > > On Sat, Aug 27, 2016 at 1:39 PM, Luiza de Oliveira Rodrigues < > [log in to unmask]> wrote: > > I agree with that too. The guideline we made falls into the category of > > > > a) were developed primarily by, and definitely for, the people that > ultimately end up using them > > b) were a credible synopsis of the best available evidence presented in a > way that clinicians could easily access and interpret > > c) allowed patient values and preferences to be taken into account (not > very explicitly, though... I will work on that!) > > > > But the resistance to it, I suppose, is exactly because of that... Some > are arguing it is too "demanding" of solid evidence to make > recommendations, when very little evidence exist. Which, of course, favors > the industry-sponsored phase II RCTs of expensive drugs, that offer > marginal benefits in non-comparative studies for a very specific profile of > patients (such as brentuximab, ibrutinib and other drugs for lymphoma). > > > > > Em sábado, 27 de agosto de 2016, Poses, Roy <[log in to unmask]> > escreveu: > > I think we are in agreement. > > My point 2 below was similar, if much too brief. > > Guidelines derived from manipulated research without appropriately > rigorous, skeptical review of same; that overemphasize published (maybe > manipulated, maybe poor quality research) without taking into account that > other research with different results may have been suppressed; and/ or > developed by conflicted guideline panels, supported by institutionally > conflicted organizations, using less than maximally rigorous, transparent, > and unbiased procedures SHOULD NOT be trusted by clinicians. I believe > many clinicians do not trust such guidelines, and hence appear "resistant" > to them. Such clinicians should not be harried, but supported. > > > > On Fri, Aug 26, 2016 at 6:42 PM, McCormack, James <[log in to unmask]> > wrote: > > Hi Roy - to be provocative, I think the following are a few reasons why > clinicians in general (especially when it comes to chronic disease state > guidelines) should be encouraged NOT to follow them - at least the way many > of them are written at present. Obviously specific guidelines/checklists > for things like surgery etc are very important but not so much for many > other conditions. > > > > 1) No more than 10% of guideline recommendations are based on RCT data > > JAMA 2009;301:831-41, Arch Int Med 2011;171:18-22, Clin Endos > 2013;78:183-90 > > > > 2) Less than 0.5% of the words in guidelines for HTN, chol, glucose and > osteoporosis relate to shared decision making or patient’s values and > preferences when in fact these conditions are all about shared decision > making > > Can Fam Physician 2007;53:1326-27 > > > > In my experience, guidelines rarely if ever provide clinicians with tools > to help them make estimates of the benefits of treatments or the potential > harms and guidelines rarely if ever are a systematic review of the > evidence. See our comment about the latest diabetes guidelines - attached. > > > > Many people are very concerned about guidelines in general which is why I > made the following video > > > > https://youtu.be/DHDnqQ_mCBA > <http://cp.mcafee.com/d/FZsS82gQcCQm1MVd55xYQsCPqaaqbParXW9J55d5VBdNB4SrdCRr5vFiIendThd79EV5kQf82JXCzB5OW30HHJzhOaInTNnhN3NlDjhOCWC-VXRDjpISrdAVPmEBC5GJPrUx-1Mn3E2M3yGEAcy1ISOeuudCXCQPrNKVJUSyrh> > > > > HOWEVER - guidelines could be great if they > > a) were developed primarily by, and definitely for, the people that > ultimately end up using them > > b) were a credible synopsis of the best available evidence presented in a > way that clinicians could easily access and interpret > > c) allowed patient values and preferences to be taken into account > > > > We tried to do that with the first ever GP developed lipid guidelines - > the major difference was that our guideline had thresholds for discussion > NOT thresholds for treatment. > > http://www.cfp.ca/content/61/10/857.full > <http://cp.mcafee.com/d/5fHCN0g4zqb0UsCyyM-qejpJ55d5VBdZZ4SyyCyYOCUOyrdCPqJyLQFm7bCXECzAQsyGq7A1mZPhOyVt1wlRSNEV5mbXUHEUxUGPFEVjtjvsZWPFISrdCM0lDlKJKmH2vMDzye8TNVYtPHpVVISOeuudCXCQPrNKVJUSyrh> > > > > Hope you find some of this of value/interest. > > > > James > > > > PS - I live in Vancouver and would love to catch up with your gang when > you come to Vancouver for the conference if you think I could provide > anything of value. I am, along with Richard Lehman, Paul Glasziou, Alan > Cassels, and John Yudkin, doing a seminar at the Overdiagnosis conference > in Barcelona at the end of September entitled "How clinical practice > guidelines for chronic prevention could reduce overdiagnosis instead of > promoting overdiagnosis" > > > > > > On Aug 26, 2016, at 11:14 AM, Poses, Roy <[log in to unmask]> wrote: > > > > I have helped give a course at Society of Medical Decision Making meetings > about why physicians do not follow clinical practice guidelines. Although > we do not have anywhere near as much data as we would like to support our > findings, we do contend that the biggest problems are: > > 1 - physicians are pushed by extraneous values (in the language of > decision psychology) or perhaps externalities (in the language of > economics) to do something other than follow guidelines. In the US, these > are often financial and bureaucratic incentives. > > 2 - physicians may have reasons to distrust the guidelines, including > > a - suspecting that the the evidence underlying the guidelines may have > been manipulated or suppressed > > b - fearing that the guidelines themselves were not based on an optimal, > evidence-based process, and may have been particularly biased by financial > relationships of the people on the guideline panels, or the organizations > that sponsored the guidelines. > > Here is a brief description of the version of the course that we will give > in October in Vancouver: > > Dr Roy Poses and Dr Wally Smith will be teaching a short course on Sunday, > October 23, 2016, at the annual North American meeting of the Society for > Medical Decision Making > <http://cp.mcafee.com/d/avndy0wrho73AQkm7PhOrdEEFELcFLLECQkkQnCkT6kjpISrlIl-BaMVsTt4QsCzAljgYwaTKqeknbEc2KKSd78GNvv5t74f5mtd7arGrXDLmtdCPpIS03EGwHM075v-sE4spuCjbX23uDBUlzcCnRnUOJI2WL_ek29ISOeuudCXCQPrNKVJUSyrh>, > in Vancouver, British Columbia, Canada. The course title will be "Why Do > Physicians Not Make Rational, Evidence-Based Decisions, and What Might Help? > <http://cp.mcafee.com/d/2DRPoAcxMsrho73AQkm7PhOrdEEFELcFLLECQkkQnCkT6kjpISrlIl-BaMVsTt4QsCzAljgYwaTKqeknbEc2KKSd78GNvv5t74f5mtd7arGrXDLmtdCPpISjDdqymphl1nHlwXUvO-klglNeWbx2S02mzkz7ls6fFilo9IzDK1NISOeuudCXCQPrNKVJUSyrh>" > We will emphasize: physician level factors, particularly the influence of > extraneous values, such as perverse incentives, including conflicts of > interest; problems with the evidence, including manipulation and > suppression of clinical studies; and problems with ostensibly > evidence-based clinical practice guidelines, especially the role of vested > interests in constructing these guidelines. > > I submit that these issues ought to be addressed by anyone who seeks to > persuade physicians to follow particular guidelines. > > > > On Fri, Aug 26, 2016 at 11:22 AM, Luiza de Oliveira Rodrigues < > [log in to unmask]> wrote: > > Thank you, Juan. > > It is a fact that good quality evidence-based guidelines are lacking. But, > still, how can we convince clinicians to pursuit them, if we also lack > objective evidence (in terms of patient outcome and healthcare system > effectiveness) that they are worth pursuing? There is a large investment > (including financial) to create these guidelines. It takes time and a lot > of effort, here in our HMO, to produce this material. It would be > tremendously helpful and encouraging if we could affirm, with some degree > of evidence-based confidence, that this is the path to better patient > outcome and healthcare system effectiveness. > > > > As I put it before, I am convinced this is the best way of practicing > medicine, but some people are not. They do accept that evidence summaries > are helpful at the point of care. But they are not convinced that > guideline-based decision making is any better than > experience-based-evidence-informed decision making. And they scrutinize > my convictions with the same standards that I scrutinize theirs, that is, > asking me for the evidence to prove it. Fair enough, I think. > > > > Of course that we know how strong the industry influence is on specialists > these days. I am not ignoring this fact. But still, I am grateful I had to > ask myself these questions, because I am collecting the material you all > kindly posted and it is already a consistent body of evidence. These > replies have been very helpful and I thank you all! > > > > Thanks again! > > Regards, > > Luíza > > > > 2016-08-26 6:01 GMT-03:00 Juan Gérvas <[log in to unmask]>: > > -i agree with the critic but no with one argument: > > *Too much evidence The second aspect of evidence based medicine’s crisis > (and yet, ironically, also a measure of its success) is the sheer volume > of evidence available. In particular*, *the number of clinical > guidelines is now both unmanageable and unfathomable. * > > -the problem is not of quantity but of quality > > -we have too much clinical guidelines of very low quality, without evidence > > -most clinical guidelines are just garbage > > -mos clinical guidelines are no EBM but "Eminence"BM, because industrial > interest > > -for example > > Royal College of Obstetricians and Gynaecologists guidelines: How > evidence-based are they? http://www.tandfonline.com/ > doi/abs/10.3109/01443615.2014.920794 > <http://cp.mcafee.com/d/FZsScxMQ721J5wsejhhovd79ISyyCyYOC--yrhhjhupjsphdCPpJmNnWkH3BPtQjhOqehld3O0HuVEVhsKwMaWXoQsyH5ZYlQsgYlpQQsFKFLKuZpQSrdCPo0auMgtH0-kfVv4aOPi5chLPadPhPBQm66n4n-jKyNNEVjKed7b1ISOeuudCXCQPrNKVJUSyrh> > > > > Eminence-based guidelines: a quality assessment of the second Joint > British Societies’ guidelines on the prevention of cardiovascular disease, > http://onlinelibrary.wiley.com/doi/10.1111/j > <http://cp.mcafee.com/d/2DRPowcCQm1MVd55xYQsCPqaaqbParXW9J55d5VBdNB4SrdCRr5vFiIendThd79EV5kQf82JXCzB5OW30HHJzhOaInTNnhN3NlDjhOCWC-VXRDjpISrdw0WMfB3PV48X4JNyh_BKnN2IIhLOaaae29ISOeuudCXCQPrNKVJUSyrh> > *.1742-1241.2007.01310.x/full* > > > > Diabetes. No significant impact of tight glycemic control on the risk of > dialysis/transplantation/renal death, blindness, or neuropathy. But 95% of > guidelines unequivocally endorsed benefit. > *http://circoutcomes.ahajournals.org/content/early/2016/08/23/CIRCOUTCOMES.116.002901.full.pdf?ijkey=hnQfo3zmmZFECR8&keytype=ref > <http://cp.mcafee.com/d/FZsSczgOrho73AQkm7PhOrdEEFELcFLLECQkkQnCkT6kjpISrlIl-BaMVsTt4QsCzAljgYwaTKqeknbEc2KKSd78GNvv5t74f5mtd7arGrXDLmtdCPpIS03JadGJPn-DqjQhGT66DQU03BGMDY9V-NfboDt5PbLoCPwA6wIi30j18A61Iq6ehhsWZQPhPt7DmPP-mgt9i4iLBzys07tGOaaGwibzgA2TCww22LBFBBLezXFISOeuudCXCQPrNKVJUSyrh>* > > > > Reporting of financial conflicts of interest in clinical practice > guidelines: a case study analysis of guidelines from the Canadian Medical > Association Infobase > http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-01 > <http://cp.mcafee.com/d/FZsS76Qm1MVd55xYQsCPqaaqbParXW9J55d5VBdNB4SrdCRr5vFiIendThd79EV5kQf82JXCzB5OW30HHJzhOaInTNnhN3NlDjhOCWC-VXRDjpISrdw0O2JyvWvcDjUCo_jy4GG-xrUjzF_bVIpOIvZchLOabPCkhjd7ab9uW9ISOeuudCXCQPrNKVJUSyrh> > *6-1646-5* > > Financial Relationships With Industry Among National Comprehensive Cancer > Network Guideline Authors > http://oncology.jamanetwork.com/article.aspx?articleid=2546172 > <http://cp.mcafee.com/d/k-Kr4wUSyMe79EEIfCzASrhhjhupjvvhdEEFELcFKcECPpISHoHZalxOVKW9EVd78GCxV0lLsQsEKngo5ttIqehly--aWe8uaIWqekTkTTfuIWrdCPpI07m5GDR8BK4tlQ6CaNaYLCNDaN_Y3MYBIpOIvYA3ATS74hOpISOeuudCXCQPrNKVJUSyrh> > > -un saludo juan gérvas @JuanGrvas > > > > > > > > > > 2016-08-26 6:54 GMT+02:00 Dr. Yasser Sami Amer <00000745ce90297c-dmarc- > [log in to unmask]>: > > Interesting article: > > http://dx.doi.org/10.1136/bmj.g3725 <http://cp.mcafee.com/d/FZsSd39J5wsejhhovd79ISyyCyYOC--yrhhjhupjsphdCPpJmNnWkH3BPtQjhOqehld3O0HuVEVhsKwMaWXoQsyH5ZYlQsgYlpQQsFKFLKuZpQSrdCPo0d0fV2IK00UzvAkmnc8ayf4mhOrVISOeuudCXCQPrNKVJUSyrh> (via @Mendeley_com) > > > > @Luiza > > > > Dear Luisa, > > Greetings > > > > Did you read this paper > > EBM a movement in crisis? BMJ 2014 > > It discusses the same argument you have kindly raised here! > > > > Regards, > > Yasser Amer > > King Saud University > > > > Sent from Yahoo Mail on Android > <http://cp.mcafee.com/d/k-Kr6xEg43qb0UsCyyM-qejpJ55d5VBdZZ4SyyCyYOCUOyrdCPqJyLQFm7bCXECzAQsyGq7A1mZPhOyVt1wlRSNEV5mbXUHEUxUGPFEVjtjvsZWPFISrdCOsVHkiPaCvypBVzxfySAWRVv5qA97_xbGhIs8ggzmi1ISOeuudCXCQPrNKVJUSyrh> > > > > > > > > > -- > > Roy M. Poses MD FACP > President > Foundation for Integrity and Responsibility in Medicine (FIRM) > [log in to unmask] > Clinical Associate Professor of Medicine > Alpert Medical School, Brown University > [log in to unmask] > > "He knew right then he was too far from home." - Bob Seger > > > > > > > -- > > Roy M. Poses MD FACP > President > Foundation for Integrity and Responsibility in Medicine (FIRM) > [log in to unmask] > Clinical Associate Professor of Medicine > Alpert Medical School, Brown University > [log in to unmask] > > "He knew right then he was too far from home." - Bob Seger > > > > > > -------------------------------------------------------------------- > Un o’r 4 prifysgol uchaf yn y DU a’r gorau yng Nghymru am fodlonrwydd > myfyrwyr > (Arolwg Cenedlaethol y Myfyrwyr 2016) > www.aber.ac.uk > <http://cp.mcafee.com/d/k-Kr3zqb0UsCyyM-qejpJ55d5VBdZZ4SyyCyYOCUOyrdCPqJyLQFm7bCXECzAQsyGq7A1mZPhOyVt1wlRSNEV5mbXUHEUxUGPFEVjtjvsZWPFISrdCM0mAfzSSVIHxISOeuudCXCQPrNKVJUSyrh> > > Top 4 UK university and best in Wales for student satisfaction > (National Student Survey 2016) > www.aber.ac.uk > <http://cp.mcafee.com/d/k-Kr3zqb0UsCyyM-qejpJ55d5VBdZZ4SyyCyYOCUOyrdCPqJyLQFm7bCXECzAQsyGq7A1mZPhOyVt1wlRSNEV5mbXUHEUxUGPFEVjtjvsZWPFISrdCM0mAfzSSVIHxISOeuudCXCQPrNKVJUSyrh> > > >